LECTURE 7B: SHOULDER EXAM/TREAT Flashcards
shoulder complex can be divided into 3 types of exam:
- UQ scan
- c-SPINE vs shoulder complex
- specific joint assessment (GH, AC, SC, ST?)
___ and shoulder complex often present similarly
spine and shoulder complex
check 4 body segments/systems review with shoulder complex
- Cervical spine
- Thoracic spine
3 .Elbow/forearm complex - Cardiovascular system
- causes of shoulder dysfunction
- Compromise of passive restraint components (INSTABILITY)
- Compromise of NM control (weak)
- Compromise of >1 neighboring joints that contribute to motion (screwed up chain)
*assume visceral and serious causes ruled out! pancoast tumor, blood clot
neighboring joints of the shoulder
AC joint, SC joint, upper thoracic spine, ribs, lower cervical spine
If shoulder pain increases with activites and patient has history of repetitive motion:
tendinopathy
If shoulder pain increases AFTER activity, and painful with prolonged static positions
instability (non-contractile tissue)
humeral epiphysitis or osteogenic sarcoma associated age
children/adolescents
RC degeneration associated age
40-60s
(may be sped up if a lot of overhead activity)
2° impingement d/t instability (caused by weakness) typically seen in
teens – 20’s … especially w/ overhead athletes
calcium deposits in shoulder are most common in _____
20-40 year olds
pain during activity ____
pain after activity _____
pain during: active mm
pain after: passive problem (instability)
Insidious onset of adhesive capsulitis typically seen
45 – 60 year olds
DM and ischemic heart disease, female sex, 45-60s age is related to ____
adhesive capsulitis
can be related to any age with trauma
MOI patterns:
Overhead exertion w/ repetitive motions
-Sub-acromial bursitis/impingement
-RC tendinopathy/tear
-Biceps tendinopathy
Fall on Outstretched Hand (FOOSH) MOI pattern:
all bets off, can sprain or break anything
Shoulder/elbow/wrist sprain or strain
Elbow/wrist fx’s
AC joint separations
Clavicle fx’s
GH joint fx’s
GH dislocations
If you fall on tip of shoulder, (adducted, land on it) MOI may cause
-AC joint separation*
-Bone contusion
-C-spine injury
MOI: shoulder pain in swimmers
-Prevalence b/t 40-91%
-Likely related to fatigue of upper back, RC and pec muscles
-Repetitive stress injury impaired dynamic stabilization of humeral head
(usually very hypermobile)
Pain relieved w/ arm elevated overhead
cause is usually
NOT SHOULDER BUT NECK
Pain relieved w/ elbow supported
AC joint separation
RC tears
Pain relieved by circumduction of shoulder w/ accompanying click or clunk
cause is
Internal derangement
GH instability
Pain relieved w/ arm distraction
Bursitis
RC tendinopathy
Pain relieved w/ arm held in dependent position
Thoracic outlet syndrome
___ may suggest instability (even if it occurred a long time ago
history of trauma (for neck we care if it is recent, but shoulder we care about forever)
What are the 4 buckets of shoulder STAR classification of shoulder pain?
- rotator cuff/impingement
- frozen shoulder
- GH instability
- post op/other catch all
key positive findings regarding rotator cuff impingement
Impingement signs
Painful arc
Pain w/ isom resist
Weakness
Atrophy (common, not always)
key negative findings with rotator cuff
significant loss of motion (joint issue, frozen shoulder)
instability signs (instability bucket)
Key positive findings of frozen shoulder
Spontaneous progressive pain
Loss of motion in multiple planes *LOSE ER FIRST WILL HAVE LIKE 10 DEGREES
Pain at end-range
key neg findings of frozen shoulder
normal motion
age less than 40
progression of impingement to rotator cuff
impingement –> RC tendon –> TEAR
50-70% of all shoulder pain seen in PT related to
ROTATOR CUFF
rotator cuff classified by tear __ and ___
type and size
small RC tear
less than 1 cm
medium RC tear
1-3 cm
large RC tear
usually includes infra
3-5 cm
massive tear
more than 5 cm
subscap +
(can go supra to subscap but usually other tendons)
___% of frozen shoulder will subsequently develop in opposite shoulder
20-30%
45-60 y/o
Females>males
Trauma
DM & thyroid disease
these are associated with
frozen shoulder
stages of frozen shoulder
Stage I (pt typically ignores) for <3 months
Stage II (freezing) for 3-9 months
Stage III (frozen) for 9-14 months –> not painful
Stage IV (thawing) for 14+ months
by 18 months, usually will resolve on its own
treatment for adhesive capsulitis
stage 1: pain control
stage 2: pain and Manual therapy
stage 3: focus on ROM, strength as tolerated (pain usually gone)
stage 4: stretch, ROM, nm re-ed, strength
Key positive findings of GH instability
Age < 40
Hx disloc / sublux
Apprehension
Generalized laxity
If patient asks about how long frozen shoulder will last, they are in stage 2, what do you say?
say recovery will last over a year most likely
-shoulder will be losing motion
-shoulder will be frozen, PT not needed
-shoulder will start regaining motion
key negative findings of GH instability
no history of dislocation
no apprehension
MRI of frozen shoulder will show
capsule INFLAMMED WHITE
post op/other differential dx includes:
- GH Arthritis
- Fractures
- Epiphysitis
- AC joint
- Neural Entrapment
- Myofascial
- Fibromyalgia
- Post-Op
GH joint instability is what?
abnormal, SYMPTOMATIC motion of GH joint affecting normal joint kinematics
laxity does not equal instability
causes of GH instability
genes
collagen
biomechanical factors
signs and symptoms of GH joint instability
feel like it will fall or slip out
pain,
sublux/dislocation
MOI of GH joint instability
Trauma
Unidirectional
Bankart
Surgery
Atraumatic, multidirectional, bilateral, rehab, inferior
what is more than 90% of of all shoulder dislocations?
anterior dislocation (automatically get a labral tear, enough times you also get a humeral head lesion)
MOI: ABD, EXT, ER
SLAP lesion looks like
RC disease and GH instability
MOI: trauma, microtrauma
posterior dislocation MOI
flexion, ADDUCTION, IR
Associated w/ seizures, electric shock, diving into a shallow pool and MVAs (football, benchpress when you are older), less than 2% of dislocations
inferior dislocation happens when
Extremely uncommon
MOI: carrying heavy objects & hyperabduction
Alterations in normal position or motion of the scapula during coupled scapulo-humeral movements (i.e. elevation)
scapular dyskinesis
MOI: bony morphology Δ’s following trauma
age: over 45
traumatic OA
separated shoulder: trauma due to falling onto tip of shoulder OR chronically trauma due to OA, RA, mechanical
AC joint dysfunction
6 types of AC joint and treatment
Types I-II – conservative management
Type III – controversial
Types IV-VI – surgical reduction
posterior dislocations of SC joint can be
life threatening!
Sprain vs dislocation 2/2 fall on flex/add or ext/add arm
Most commonly fx’d bone in childhood
clavicle
5-10% of all fxs in body
Most common humeral fracture in children & elderly
proximal 1/3 of humerus (ice cream cone!)
FOOSH or fall right on it.
TSA/RTSA involves
whacking humerus with spike
scapular fxs are __% of all fxs in the body
1%
(usually immobilization, ORIF if displaced)
outcome measures of the shoulder
DASH
QuickDASH
